CLM-2026-022760
Summit Family Practice, Family Medicine. Service 2026-06-02 at office (POS 11). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Samuel Daniels
- Member ID
- UHC-88956-84
- Date of birth
- 1987-06-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419237
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6652
- Coverage period
- 2021-11-01 to present
- Deductible
- $504.34 of $2,500.0020%
- Out-of-pocket maximum
- $1,336.91 of $5,000.0027%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9865039744
- Network
- In network
- Rendering NPI
- 7864322707
- Location
- Scottsdale, AZ · TIN 65-7813683
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $210.00 | $130.20 | — | — | DeniedCO29 |
| Totals | $210.00 | $130.20 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-586275
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039157 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-02: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Fail | CO29 | Received 124 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Family Practice (9865039744). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Family Practice2026-06-02 12:46
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-10-04 06:40
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-04 12:20
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 124 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001626 | 2026-06-09 | Northgate Clinical Laboratories | $208.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.